A nurse is providing teaching to an assistive personnel (AP) about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?
Secure the client's restraints with a square knot
Attach the restraints to the fixed portion of the frame of the client's bed
Remove the client's restraints every 2 hours
Allow 1 fingerbreadth between the restraint and the client's wrists
The Correct Answer is B
A. Secure the client's restraints with a square knot
This is incorrect because square knots are difficult to release in an emergency. Quick-release knots are recommended for safety.
B. Attach the restraints to the fixed portion of the frame of the client's bed
This is correct because attaching restraints to the bed frame ensures they remain stable and do not pose a risk if the bed position changes. Restraints should never be attached to movable parts like side rails, as this can lead to injury.
C. Remove the client's restraints every 2 hours
This is a common practice, but not specific enough for the primary focus of the question. While restraints should be removed periodically to check for circulation, skin integrity, and range of motion, the interval might vary based on institutional policy and patient needs.
D. Allow 1 fingerbreadth between the restraint and the client's wrists
This is incorrect because the proper fit is typically 2 fingers to ensure the restraint is snug but not too tight, preventing circulation issues or injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Providing the client with written information in their spoken language is the appropriate action for the nurse to take. This would ensure that the client understands the information and can refer to it later. It would also respect the client's culture and preferences.
Choice B reason: Speaking very slowly during the teaching session is not an appropriate action for the nurse to take. This would not improve the communication or comprehension of the client. It might also be perceived as patronizing or disrespectful by the client.
Choice C reason: Using medical terminology while explaining the medications is not an appropriate action for the nurse to take. This would confuse the client and hinder the learning process. The nurse should use simple and clear language that the client can understand.
Choice D reason: Having the client's family member who is present interpret is not an appropriate action for the nurse to take. This would compromise the accuracy and confidentiality of the information. It might also create a conflict of interest or a bias for the family member. The nurse should use a professional interpreter or a translation device if available.
Correct Answer is B
Explanation
Choice A reason: Placing a surgical mask on the client during transfer to the unit is not an appropriate action for the nurse to take. Cutaneous anthrax is not transmitted through respiratory droplets, but through direct contact with the spores that enter the skin. A surgical mask does not protect the client or others from the infection.
Choice B reason: Preparing to administer antibiotics to the client is an appropriate action for the nurse to take. Cutaneous anthrax is caused by a bacterium called Bacillus anthracis, which can be treated with antibiotics, such as ciprofloxacin or doxycycline. Antibiotics can prevent the infection from spreading to other parts of the body and causing serious complications.
Choice C reason: Planning to administer an antiviral medication to the client is not an appropriate action for the nurse to take. Cutaneous anthrax is not caused by a virus, but by a bacterium. Antiviral medications are ineffective against bacterial infections and may cause adverse effects or interactions.
Choice D reason: Wearing an N95 respirator mask while caring for the client is not an appropriate action for the nurse to take. An N95 respirator mask is used to protect the nurse from airborne pathogens, such as tuberculosis or measles. Cutaneous anthrax is not airborne, but contact-based. The nurse should wear standard precautions, such as gloves and gown, and wash their hands thoroughly after caring for the client.
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